Pronouncing Someone Dead

When I was an intern in internal medicine, I admitted a patient to my service with pancreatic cancer. Pancreatic cancer is a bad one; back then, only ten percent of patients with it would be alive within five years after being diagnosed. My patient was a farmer in the full bloom of late middle-age health when he began rapidly losing weight. An abdominal CT scan ordered by his primary care physician revealed the cause: a three centimeter mass in the body of his pancreas. It had already metastasized to his lymph nodes and liver. He went downhill quickly and was admitted to my service within two months of being diagnosed for palliative care. I ordered a morphine PCA (patient controlled analgesia) pump, which immediately made him comfortable, and then essentially waited for him to die.

It happened one night when, thankfully, I was on call. His nurse paged me. “I think he’s gone. Can you please come and pronounce him?”

I’d never pronounced anyone dead before. I’d never even seen a dead body in real life outside of the cadaver I’d dissected in my first year of medical school. But this experience, like that one, was a rite of passage I’d known no doctor got away with missing, so I’d prepared. When my patient had first been admitted, I’d asked my senior resident how one went about making certain a patient you thought was dead had actually died.

“You listen for breath sounds,” he’d told me, “and for a heart beat. Check for a response to deep pain. If you want, you can verify lack of brainstem activity by looking for an oculocephalic reflex.” That last maneuver consists of turning the head rapidly in one direction and watching to see if the patient’s eyes remain focused on the midline or continue to point in the direction of the head, like the painted-on eyes of doll. The presence of “doll’s eyes” tells you that the most elemental brain functions have ceased.

When I entered my patient’s room, I found myself confronted with at least ten people—family members—and a priest. My patient’s wife was sobbing over my patient’s bed.

The priest gave me a knowing look and nodded somewhat nervously. “I think…” But his voice trailed off.

I nodded back. Then I approached my patient. I realized instantly none of the maneuvers my resident had suggested was actually necessary. My patient lay on his back in a way even sleepers never do: without any movement of any part of his body whatsoever, a condition I recognized as distinctly unusual only in that moment of first seeing it. I wasn’t struck so much by the complete absence of the rhythmic rise and fall of breathing as by the strange slackness I could see in every part of him, especially in his face and jaw. I knew before I touched him that my patient was dead.

Nevertheless, I put my stethescope to his chest. His wife backed away quickly, with a movement that suggested desperation—perhaps, I thought, for me to tell her she was mistaken in her belief that he was gone. I watched and listened for breathing, acutely aware the entire room had paused to hold its own collective breath. I heard nothing. It was the first completely silent chest to which I’d ever listened.

I stood up and nodded. “He’s gone,” I said quietly.

At that moment, my patient’s wife let out a wail, the sound of which I will never forget, and collapsed on top of her husband’s body. I looked at the priest, who nodded to me again, this time with more confidence. Now he knew his role, a role I imagined he’d played numerous times before.

I don’t remember the specific reactions of the other family members in the room. I left quickly to leave them all to their grief.

That night I learned about death certificates (and how notoriously inaccurate the cause of death printed on most of them is), the transportation in hospitals of dead bodies (in zipped-up, black burlap bags), morticians, and funeral arrangements. And the critical importance of one thing more that, until that night, I’d never thought about even once: rituals.

Why do we have funerals for the dead? They’re gone and know nothing about them. Why do we celebrate the birth of newborns whose eyes can barely see five inches in front of their faces?

The obvious answer is that these rituals are for everyone except those for whom we hold them. Psychologically, rituals seem an invaluable aid to mark transitions—especially painful ones—with some kind of formality. Rituals held around transitions make the transitions seem more real somehow, especially when the transition is one we’ve dreaded and don’t want to believe has actually occurred. Often it’s the ritual to which our memories return and the ritual on which they rely to explain to us what happened that day when our loved one was lost, rewriting the experience into a particular story that only partially reflects the truth of what happened as we know memory does—hopefully in a way that makes it easier to bear.

Which is why rituals are so important. The experiences for which we create them may be painful, but the rituals themselves can be imbued with loving care. Patients, for example, have been found to recall the way doctors deliver bad news for the rest of their lives, recounting the story of their experience over and over again to friends and family members, focusing not so much on a retelling of the bad news itself but on how they were treated by the doctor delivering it.

Doctors play a unique role in helping people through transitions with rituals. My patient’s family needed the ritual of my officially pronouncing my patient dead in order to begin the process of grieving. Patients in general need to go through the ritual of receiving an official diagnosis in order to begin marshaling the emotional energy they’ll need to withstand whatever treatment is offered. People often create rituals for themselves to help them through difficult transitions as well: they throw out all keepsakes from failed relationships; they give away their dead loved one’s clothing to charity; they attend graduation ceremonies.

It seemed to me as if my patient’s family needed me to pronounce my patient dead before they would believe it even though they already knew it. It made me realize how much rituals matter and how we can harness their power by fully giving ourselves over to them. When life brings us to a transition point, especially a painful one, we shouldn’t underestimate the power of marking them with a ritual. It just may provide us the comfort we need to make it through to the other side.

Some hours after I’d pronounced my patient dead, the priest appeared at the nurse’s station where I sat. “That was a difficult moment,” he said after a pause. “But a moment they needed. Thank you for your kindness.”

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I started working before I got my college diploma and never went through graduation. To this day I still have the occasional nightmare I didn’t graduate!

And I learned my lesson about the importance of rituals.

Before I got married (the first time), I used to sit in the church and think about walking down the aisle and into a new life. Before my divorce (which I didn’t want and hadn’t seen coming), I used to sit in the empty courtroom—and think about watching it all end. That isn’t how it worked out, but I’ve often wondered how much faster I would’ve healed if it had.

Wow! Really great post, Alex. I’m really fascinated by death and you gave a superb description of what occurred w/your patient. And, yes, how important those words are of the doctor. When my dad was diagnosed w/a brain tumor that metastasized from his lung cancer, Dr. Day’s kindness will always be remembered by my family and myself. My mom is a healthy 88 and we joke about her impending death. You gotta!

In those several deaths at which I have had the privilege to be in attendance, I have always been struck by how peaceful people look at the moment of death: as if all their suffering has been released. All the pain and “worry lines” disappear. There is a beautiful Japanese film called “Departures” (winner of the best foreign language film Oscar for 2009) which speaks to the healing power of ritual around the time of death. I highly recommend it.

When my father died in bed, with me standing at his side, I felt sad and relieved. He had suffered too long; now there was peace.

My mother died 24 hours later from a massive stroke. Her death was jarring. Unexpected. Sorrowful. The oddest part was calling the funeral home to say she had died; we wanted a double funeral.

My sister and I followed the traditions & rituals that my parents wanted. The funeral service was a tribute to my parents. Relatives and friends and community members came together to mourn. We were comforted by the people and memories. They were buried beside a brother, and sisters and brother in law, a niece and her husband.

Your post reminded me of the series of photos shown in the New York Times several years ago. Patients were shown in late life, and then after death (sans any prep by morticians), and a brief bio was given for each person. The sense of peace was evident in each of the post-mortem photos, despite the troubled lives some had lived.

Kids are hard—but no less than adults, as long as it’s expected. If not, it’s horrific either way.

One young girl I had the privilege to pronounce had been with us in hospital for 14 months. Her ritual of leaving us sticks with me.

She was a very girly girl before her illness robbed her of her communication: pink, sparkles, fairies. After she died, she was laid out in the hospital room that had become her home, wearing a white satin dress.

Each of us who wished were invited to sew a crystal butterfly onto her skirt. This was a task that took five minutes—five minutes to spend sitting quietly with her family, five minutes that gave us a goal and something to do with our hands, five minutes to bid her farewell.

My mother passed in a hospice where the staff—down to the last person was enormously kind, considerate, and compassionate. About a day before she died, a hospice nurse told me that she had less than a day before she would be gone. She had seen it so many times before that she was accurate almost to the hour. It gave my family and I an opportunity to say goodbye even though she was no longer awake. I remember watching her last breath and the pulse of the carotid artery that continued to pulse for a few more beats. And then she was gone. I am deeply grateful for the chance to see her into the next life. I will always remember the kindness of the staff who helped me with this final goodbye.

My aunt died a few weeks ago and I was in the room as she was going and her face was so gray, it was almost white (as the life force was leaving?). Then after we knew she was gone, a bit of color returned; is that the way it is? Thanks so much for you article. I appreciate your compassion and caring and this site especially.

I find this topic so comforting today. We don’t often discuss the moment of death or the experiences that some of us have had. Thank you for leading us down this path.

The afternoon that my dad passed away, I knew from the moment of his stroke that morning that our lives were going to change forever that day. We were able to call everyone together to say our goodbyes. At the moment that he died, I felt a lifting and lightening in the room. I have often thought of it as the whirl of a dust devil. He was a naturalist and outdoors-man and would have loved that analogy.

Thank you for the wonderful post. I lost my father suddenly when I was 10 years old, and although my mother was asked if she wanted to view the body (and declined), I was not. I really wanted to, and have always regretted not having that chance for closure, or to say goodbye.

I will second Linda Rice’s recommendation for the movie “Departures”—it was really great!

Also, thank you Melt for sharing the ritual of sewing the butterflies onto the little girl’s dress, for all the reasons you cited.

And a third recommendation here for the film “Departures.” It treats a subject one usually avoids, but that’s exactly why it ought to be talked about and it’s what gives the film it’s humor and poignancy.

Well said. If only the rituals you described here were more common than the ritual that most commonly happens in the hospital—doctors, nurses, code carts coming into the room to perform CPR on a dying patient with metastatic disease as no one ever discussed their end-of-life wishes. This ritual is full of pomp and circumstance but far to often comes with it a known outcome.

Alex,
I really enjoyed this post for many reasons. Thank you for your transparent retelling—I’m not a morbid person but I wonder what those final moments are like—I don’t know…I feel like it will make me feel more prepared when I’m standing at a loved one’s bedside for the final time.

I was just talking with a friend yesterday about how so many doctors seem to lack the social skills when dealing with patients on very personal matters—sometimes life and death matters.

That’s such an important part of being a doctor—I wish more doctors were as sensitive to there patient’s emotional needs as you are.

I don’t think I’ve ever had the “benefit” of a ritual for both the death of my father and mother, Alex. The monitoring machine was turned off and the moment of death just seemed to quietly come, knowing that there was no longer breath nor anima that emanated from either my parents upon dying in the hospital. My mom simply looked exhausted at her death. Not long afterward I dreamt of her in a very strange and eerie dream as I found her in a very dark passageway, in a dark chamber by herself. She awoke and looked up at me, both of us startled at the site of each other. The following dreams after that were happier dreams of seeing her in action, serving refreshments, and preparing to greet people at some function. The last dream I had were of them together, my mother & father, in some dormitory sharing conversation and giving me knowing looks toward me that everything was all right with either of them.

Not long ago I got a diagnosis of PKD, a condition for which there is neither cure nor treatment. It gradually destroys the kidneys, leading to dialysis and death. Transplant is sometimes an option, unless something else cuts in line and takes you out first. My point, though, is that finding out what’s most likely to kill you has an odd effect. My first reaction was the thought “everything’s changed.” About 20 minutes later the punchline drifted by: “Yes, everything changed, but nothing’s different.” That’s not quite it either. Priorities ease and direct focus on the bubble of no-time becomes paramount. It seems that the reaction to this news forecasts the mix of grief and relief that survivors all must experience, though not necessarily at once.

I have somewhere between four and nine years to finish coming to terms with my death, which seems like a huge luxury.

Graycard: Obviously I don’t know the specific details of your case, but you should know people can live for years, if not decades, on dialysis. Your prognosis is likely somewhat brighter than your comment makes it sound.

Thanks for the reassurance, but since I’m in my 70’s I doubt I’ll have decades ahead. Dialysis doesn’t sound like a lot of fun, but then Osama’s thriving on it, we’re told. So whatever. It still seems a luxury to have my mind focused on that eventual necessity.

I wonder, though: do people who die suddenly have that experience? No telling, I guess.

[…] plans to see one another. I’ve written about the value of such rituals in a previous post, Pronouncing Someone Dead (sorry for all the morbid titles), and won’t repeat those ideas here. Suffice it to say […]

My mother was in the hospital in a coma from a stroke for four days when my sister and I were at her bedside at three in the morning. I closed my eyes and said a prayer asking God to let her suffering end. When I opened my eyes my mother was looking at me with “doll eyes” and smiling. They said “How sweet. She’s saying goodbye.” She died seconds later. As my sister and I left the hospital I said we were very lucky to escort the woman that gave us birth out of this world.